Michael Sandow

A Comparison Of Pain, Strength, Range Of Motion, And Functional Outcomes After Hemiarthroplasty And Total Shoulder Arthroplasty In Patients With Osteoarthritis Of The Shoulder: A Systematic Review And Meta-analysis

BACKGROUND A systematic review of the literature was performed to estimate the impact of hemiarthroplasty compared with total shoulder arthroplasty on function and range of motion in patients suffering from osteoarthritis of the shoulder. METHODS We conducted an electronic search for relevant studies published in any language from 1966 to 2004, a manual search of the proceedings from five major orthopaedic meetings from 1995 to 2003, and a review of the reference lists from potentially relevant studies. Four randomized clinical trials, with similar eligibility criteria and surgical techniques, that compared hemiarthroplasty and total shoulder arthroplasty for the treatment of primary osteoarthritis of the shoulder were found to be eligible. Authors from three of the four studies provided original patient data. Analysis of covariance focused on the two-year outcome and included a comparison of the aggregate University of California at Los Angeles shoulder score, four University of California at Los Angeles domain scores, and range of motion. RESULTS A total of 112 patients (fifty managed with hemiarthroplasty and sixty-two managed with total shoulder arthroplasty), who had a mean age of sixty-eight years, were included in this analysis. A significant moderate effect was detected in the function domain of the University of California at Los Angeles shoulder score (p < 0.001) in favor of total shoulder arthroplasty (mean [and standard deviation], 8.1 +/- 0.3) compared with hemiarthroplasty (mean, 6.6 +/- 0.3). A significant difference in the pain score was found in favor of the total shoulder arthroplasty group (p < 0.0001). However, the large degree of heterogeneity (p = 0.006, I(2) = 80.2%) among the studies decreased our confidence that total shoulder arthroplasty provides a true, consistent benefit with regard to pain. There was a significant difference in the overall change in forward elevation of 13 degrees (95% confidence interval, 0.5 degrees to 26 degrees ) in favor of the total shoulder arthroplasty group (p = 0.008). CONCLUSIONS At a minimum of two years of follow-up, total shoulder arthroplasty provided better functional outcome than hemiarthroplasty for patients with osteoarthritis of the shoulder. Since continuous degeneration of the glenoid after hemiarthroplasty or glenoid loosening after total shoulder arthroplasty may affect the eventual outcome, longer-term (five to ten-year) results are necessary to determine whether these findings remain consistent over time.

Proximal scaphoid costo-osteochondral replacement arthroplasty

Deficiency of the proximal pole of the scaphoid due to fracture or necrosis was treated by costo-osteochondral replacement arthroplasty using rib bone/cartilage autografts in 22 patients who were followed prospectively and assessed at a median 24 month follow-up (range, 12–72 months). Improvement of wrist function occurred in all patients with increased motion, improved grip strength and less pain. The average modified Green and O’Brien Wrist Function Score improved from 53 out of 100 preoperatively to 80 at the most recent review. All patients were graded fair or poor at initial review and all but three improved to good or excellent at the most recent assessment. Despite the absence of the scapholunate ligament, carpal alignment did not deteriorate in any patient and there were no graft non-unions or significant complications. In the short and medium term a costo-osteochondral autograft can satisfactorily restore mechanical integrity of the scaphoid proximal pole and maintain wrist motion while avoiding the potential complications of alternative replacement arthroplasty techniques.

Current Practice of Primary Flexor Tendon Repair: A Global View

In this article, a group of international leaders in tendon surgery of the hand provide details of their current methods of primary flexor tendon repair. They are from recognized hand centers around the world, from which major contributions to the development of methods for flexor tendon repair have come over the past 2 decades. Changes made since the early 1990s regarding surgical methods and postoperative care for the flexor tendon repair are also discussed. Current practice methods used in the leading hand centers are summarized, and key points in providing the best possible clinical outcomes are outlined.

IFSSH Flexor Tendon Committee report 2014: from the IFSSH Flexor Tendon Committee (Chairman: Jin Bo Tang).

Hand surgeons continue to search for the best surgical flexor tendon repair and treatment of the tendon sheaths and pulleys, and they are attempting to establish postoperative regimens that fit diverse clinical needs. It is the purpose of this report to present the current views, methods, and suggestions of six senior hand surgeons from six different countries — all experienced in tendon repair and reconstruction. Although certainly there is common ground, the report presents provocative views and approaches. The report reflects an update in the views of the committee. We hope that it is helpful to surgeons and therapists in treating flexor tendon injuries.

Hemiarthroplasty vs total shoulder replacement for rotator cuff intact osteoarthritis: how do they fare after a decade?

BACKGROUND We compared hemiarthroplasty (HA) and total shoulder replacement (TSR) for the treatment of osteoarthritis at minimum of 10 years from primary arthroplasty. METHODS Thirty-three patients (13 HA and 20 TSR) were intraoperatively randomized to HA or TSR after glenoid exposure and were assessed to a minimum of 10 years postoperatively. Apart from those who died, no patients were lost to follow-up. RESULTS At 6 months and 1 year, the TSR patients had less pain than the HA patients (P < .05), and this became more apparent at 2 years postoperatively (P < .02). There were no statistically significant differences between the groups at 10 years with respect to pain, function, and daily activities. No patients in the HA group rated their shoulders as pain-free at 10 years; however, 42% of the surviving TSR patients rated their shoulders as pain-free at 10 years. Four HA patients were revised to TSR due to severe pain secondary to glenoid erosion. Two shoulders in the TSR group have been revised. Nine of the 13 HA patients (69%) and 18 of the 20 TSR patients (90%) remained in situ at death or at the 10-year review. CONCLUSION TSR has advantages over HA with respect to pain and function at 2 years, and there has not been a reversal of the outcomes on longer follow-up. This longer-term review does not support the contention that HA will avoid later TSR complications, and in particular, an unacceptable rate of glenoid component failure.

Intercarpal arthrodesis by dowel bone grafting

Successful intercarpal arthrodesis requires a stable fusion with maintenance of correct alignment and spatial relationship of the carpus. The technique described utilizes a series of tube saws to fashion the arthrodesis bed and then insert a sized iliac crest dowel bone graft with a tight interference fit. This technique has been used in 24 patients over a two-year period in both medial and lateral column intercarpal fusions. All wrists had fused by the tenth post-operative month. The technique is precise, reproducible and technically simple with a high fusion rate and minimal donor site morbidity.

A comprehensive classification of proximal humeral fractures: HGLS system

BACKGROUND This study assessed the intraobserver and interobserver reliability of a binary classification system using an easy-to-remember acronym (the HGLS system--based on the reappraisal of Codmans description by Hertel et al) and compared it with the AO and Neer systems. MATERIALS AND METHODS Forty-seven proximal humeral fractures in 47 patients treated at the Department of Orthopaedics and Trauma, Royal Adelaide Hospital, Adelaide, Australia, were identified in the period from July 2007 until January 2008. Fractures of the proximal humerus were examined with anteroposterior, lateral, and axillary radiographs. Three independent reviewers classified the fractures using the AO, Neer, and HGLS systems. Reclassification of the same fractures was undertaken after a 6-month interval, and interobserver and intraobserver correlation, by use of the κ statistic, was calculated for all 3 classification systems. RESULTS The mean age of patients was 64.5 years (range, 16-95 years). The interobserver correlations for the AO system (κ value, 0.47) and Neer system (κ value, 0.44) were graded as poor and were consistent with the values of previously published studies. The HGLS classification showed good interobserver agreement for all 3 examiners at the first interpretation (κ value, 0.73) and second interpretation (κ value, 0.61). Good intraobserver agreement after a 6-month period was also seen for the HGLS classification (κ values, 0.87-0.92) compared with the AO system (κ, 0.61-0.71) and Neer system (κ, 0.42-0.77). CONCLUSION The HGLS system provided a more reliable description of fractures of the proximal humerus compared with the Neer and AO systems. Further studies are necessary to assess the validity of the HGLS system.

Total shoulder arthroplasty using trabecular metal augments to address glenoid retroversion: the preliminary result of 10 patients with minimum 2-year follow-up

BACKGROUND Options to address glenoid retroversion include eccentric reaming, bone grafting, modifications to component shape, and reverse shoulder arthroplasty. Trabecular metal (TM) augments have been used extensively in the hip and knee to address bone deficiency in arthroplasty as part of a hybrid combination of high-density polyethylene, polymethyl methacrylate, and TM. This study presents the initial results of the use of specifically designed augments in the shoulder to address glenoid retroversion as part of total shoulder arthroplasty (TSA). MATERIALS Ten patients (4 women and 6 men; aged 60 to 79 years) with Walch grade B2 or C glenoids have undergone TM glenoid augment insertion as part of a TSA, with a longer than 24-month follow-up. Patients received a 15° or 30° TM wedge to correct excessive glenoid retroversion before the glenoid component was cemented. Outcome analysis was performed preoperatively, at 3, 6, and 12 months, and yearly thereafter. RESULTS All patients have been satisfied, and all scores have improved. There have been no complications and no hardware failures or displacement. All glenoid components were implanted to within 10° of neutral glenoid version. Radiographs at 24 months show good incorporation of the TM augment and the glenoid component. CONCLUSIONS The TM augments have the advantage of immediate secure fixation, no tendency to collapse, and the ability to correct retroversion of 25° or more. This study confirms the successful short-term outcome of wedge-shaped TM augments to correct glenoid retroversion as part of TSA.

Distal biceps tendon partial tear presenting as a pseudotumor

Department of Orthopaedics and Trauma, Royal Adelaide Hospital, Adelaide, South Australia, AustraliaSoft-tissue sarcomas are the most common malignancyof the extremities. Treatment is intense, and morbidity andmortality rates are high. The upper extremity accounts foraround 20% of all soft-tissue sarcomas,

The why, what, how and where of 3D imaging

The collection of articles in this issue provides an indication of the increasing use and value of threedimensional (3D) imaging in hand surgery. Increased access to 3D visualization techniques enables accurate diagnosis, improved comprehension of anatomical and pathological complexities, and potentially more reliable treatments, particularly of the wrist. 3D imaging is a natural evolution of computer tomography (CT) and magnetic resonance imaging (MRI) that capture 3D data, but traditionally transform this data into a 2D planar representation to allow a more familiar appreciation. The reality is, clinicians need an appreciation of patho-anatomy in 3D. Access to, and interaction with, image data within a 3D environment is likely to improve a clinician’s 3D comprehension. There are a number of challenges in the successful utilization of 3D. These can be explained and contextualized as the ‘Why, what, how and where’ of 3D imaging. The ‘WHY’ has been highlighted above, in that ultimately it is the surgeon’s 3D interpretation of the pathology that is key to improving patient care. Diagnostic imaging investigations are performed in large part to assist this 3D appreciation. In this issue, Garcia-Elias et al. (2014) demonstrate clearly the value of achieving a 3D perception of wrist motion and the implications for post-repair rehabilitation. In an earlier publication, Kunz et al. (2013) highlighted the value of planning the surgery prior to performing a multiplanar osteotomy. This is much more difficult and unpredictable if relying on the 3D perception of the surgeon, based on reviewing of 2D images, as done previously. These articles highlight the critical technical reality in that what is called 3D imaging is not a single entity. What type of 3D data is captured, and how it is displayed, will depend on the need, as well as the advantages and limitations of each type of data display technology – The ‘WHAT’. The ‘WHAT’ is a more difficult problem, and is at the core of the confusion over 3D imaging. There are essentially two distinct forms of 3D imaging or more specifically 3D data presentation. These are Volume Rendering (VR) and Surface Rendering (SR). The image data of the anatomical part studied is captured, particularly in CT scanning, as a series of points in space (called voxels – ‘3D pixels’), that have a specific spatial (x,y,z) location, and radiological (Hounsfield) density values. In VR, these 3D data points are given a visual attribute such as colour or variable transparency, and the resulting image is projected as a type of shadow against the incident or viewing surface. This is thus a 2D projection of the 3D data set. This can be seen as a sort of coloured shadow of, for example, a tree projected onto a window. What is available is not a 3D model or object, just the projected 3D data on to a screen as a 2D image. This is called ray casting, which is a way to achieve a 2D projection of the 3D data, but not a true 3D object or model. As no actual 3D object is created, although the viewing aspects and proximity can be changed and areas can be masked out or hidden, it is not possible to manipulate or interact with the apparent 3D image, which in reality is a projected 2D image. Consequently, measuring distances, for example, is difficult as the measurement tools are applied to the projected imaging, not the actual 3D data points. Out-of-plane measurements are particularly unreliable. The images created can be shared as a series of screen captures (snap shots of a particular view), or alternatively, the entire data set can be shared, plus the various data manipulation values to reproduce the previously demonstrated views. This latter option requires significant computer capacity and is usually confined to the work stations attached to the CT scanner. The majority of radiology imaging utilized today is based on VR. This has many advantages, including speed of image creation and the ability to fade and vary the transparency to provide appealing visual representations. As VR can provide a rapid simulation of the 3D anatomy, it is particularly useful in displaying moving anatomy, such as the motion of the heart, or to provide an impression of 3D motion of joints, as displayed in the article by Garcia-Elias et al. (2014). 524137 JHS39410.1177/1753193414524137The Journal of Hand SurgeryEditorial research-article2014